In their new book, Psychiatry Under the Influence, Robert Whitaker and Lisa Cosgrove detail the ways in which economies of influence lead institutions to act in ways antithetical to their stated mission. They use this overarching framework to examine the actions of the America Psychiatric Association and academic psychiatry. Their convincing argument is that the actions of the institutions strayed towards the protections of the institutions and organizations at the cost of their stated mission to further the understanding of psychiatric disorders and improve treatment.
But institutions are made up of individuals and the authors wonder how well-intentioned individuals could have been led to act in this way. Their argument is that in most instances this was not done out of a conscious attempt to deceive but out of a kind of self-deception. They rely in this section of their book on the work of cognitive psychologists and they specifically cite the work of Carol Tavris and Elliot Aronson who summarize their own work and that of others in the book, Mistakes Were Made (but not by me).
Psychiatry Under the Influence is primarily concerned with modern America psychiatry beginning with the publication of the DSM III in 1980. I started medical school in 1977 and my interest in psychiatry began early. It was psychoanalytic thinking that initially drew me in but over time I was drawn more towards the study and treatment of those who experience psychosis. I left the academic world as the newer drugs were being introduced in the early 1990’s and I worked in a community mental health center during the era when it was not uncommon for drug reps to drop by on a regular basis touting their newest products.
So this history of psychiatry detailed in Psychiatry Under the Influence is my era and its twists and turns are the twists and turns of my own career. I wonder how I could have held tightly on to beliefs that I now see as suspect and I wonder how and if I can avoid this going forward. So after finishing Psychiatry Under the Influence, the next book I picked up was Mistakes Were Made.
The authors focus on the concept of cognitive dissonance “a state of tension that occurs whenever a person holds two cognitions (ideas, attitudes, beliefs, opinions) that are psychologically inconsistent.” They describe self-justification as the rationalizations one constructs to resolve and mitigate these inconsistencies. As applied to the form of psychiatric behavior that is most criticized on MIA, for example, it helps us understand why most psychiatrists ignored their conflicts of interests for so many years. If a psychiatrist has a self-perception as being an intelligent and rational person, then he might not think himself capable of being influenced by advertisement. He might think he is able to distinguish between marketing and science and therefore able to go to a drug company sponsored symposium – or even more important presenting a talk at one of these symposia – and not be influenced in an inappropriate way.
Even when confronted with data suggesting the opposite is true – doctors in general will prescribe more of a drug after attending that manufacturer’s sponsored talk – most of us think of ourselves as impervious to these pressures (although we are likely to be concerned about our colleagues’ behavior). I have wondered whether there may be something about medical training that leads us to be more rather than less vulnerable to these kinds of influences. It is hard to get into medical school and many of us who are accepted get there after years of high academic achievement. It is understandable that by this point we would have a reasonable sense of ourselves as intelligent people. However, medical training although based on science is not a scientific activity.
There is so much to learn that we mostly just need to accept that those who are teaching us have evaluated the data fairly. The act of completing medical school is much more an act of memorizing massive amounts of data and assimilating to a medical culture than of applying the scientific method of developing hypotheses and testing them. If it were otherwise, we would be in medical school until we were ready to retire! When we finish, we are asked to make multiple decisions daily about people’s treatment.
We need to act quickly and decisively. We need a template that we can trust and we need to rapidly build up trust in our own judgment. To use the framework of cognitive dissonance, it would be too uncomfortable – probably immobilizing- to acknowledge at every moment how much we do not know. So we do the best we can. The best among us, hold on to that uncertainty with grace. In my opinion, Atul Gawande seems to capture this spirit in his writings. But others seem to overstate the knowledge base and, in this context, Jeffrey Lieberman comes to mind.
In chapter 10 of Psychiatry Under the Influence, Whitaker and Cosgrove use the model of cognitive dissonance to examine the behavior of many of psychiatry’s most influential leaders over the past 20 to 30 years. So it was interesting for me to read that while Tavris and Aronson also had a chapter focusing on psychiatry (and psychology), they did not discuss the DSM or the marketing of drugs but rather the era of the so-called recovered memory movement that swept the US in the 1980’s.
During this time, there was a belief that since people who had been abused as children were often noted to suffer as adults with a variety of problems such as anxiety, depression, eating disorders, that others who came to treatment with those same symptoms might have also experienced abuse even if they did not recall this. They identify this as a logical fallacy. Using hypnosis and other techniques, many people did recall such memories. Over time, recollections of more fantastic proportions were recalled – satanic cults and ritualistic abuse, for example – and parents were charged with crimes and convicted on this basis alone. Families were torn apart.
In light of this, researchers began to systematically study memory. The notion of recovered memory came from the psychoanalytic literature of repression. But people who studied memory had not found that memories are stored intact, perfectly preserved without distortion. In fact, memory is fungible. Not only that, memories can be created. In the Tavris and Aronson book, they wonder not about psychiatrists who may hold on to ideas of the benefits of drug in the face of emerging data but about psychiatrists (and many others) who hold on to their belief about memory in the face of emerging data that challenges these ideas.
Why do I bring this up here and now? I think a cautionary tale is warranted. To the extent that a person who holds a privileged position can understand the plight of those who hold less power, I can at least say I understand why so many people are angry at psychiatry as an organization and as embodied by individuals. But I continue to think this is a field – and in this I include us all: other professionals, family members, those with lived experience – of great uncertainty. We can do harm in a number of ways and we may disagree on many points but perhaps certainty is the one thing we can collectively hold as suspect.
Concepts such as cognitive dissonance are not concepts that are applied by experts and used to undermine the credibility of one class of humans, but is a comment on the vulnerability of human thought in general. I am as vulnerable as anyone else. Even as I write this I worry about alienating people who I have come to consider allies. I find myself holding back on criticisms of people I like or know more than on people who stand in as more distant icons. It is easier to write a sentence critical of Jeffrey Lieberman than of my friends and closer allies.
But I will write this: I do not think any history of American psychiatry is complete without a full understanding of the role of psychoanalytic thinking. Psychoanalysts dominated the profession in the US for about 30 years and I agree with Tavris and Aronson that there were elements of the psychoanalytic structure that made the recovered memory era possible. This time is an important one on so many levels. People were harmed – mistakes were made – and not being able to speak up sooner and call out colleagues who seemed to have gone astray was a part of that story.
We continue to be extremely concerned about the aftermaths of trauma and child abuse and I understand that some people’s memories are discounted. But discounting memories is not the same as helping to create them. And acknowledging the faulty nature of memory is not the same as dismissing a person completely. Understanding what left the professions involved so vulnerable to this kind of problem is as important as understanding the impacts of the pharmaceutical industry on the practice of medicine.
But this worry goes well beyond the concept of recovered memory. We all experience confirmation bias- the tendency to hold on to ideas that confirm our world view and discount those that do not. Tavris and Aronson write about the “closed loop” of psychotherapy – where any idea or behavior that emerges within the treatment can be justified within the guiding paradigm of the treatment. If someone does well in the treatment, then the intervention is proved to be successful. If they do not improve, there is often a way to justify this in the context of the person’s own psychology.
Never mind that most people improve without treatment or that most of our treatments are just not all that effective. There are many remarkable and innovative initiatives being pursued around the world. This is exciting. But there is a danger of selection bias – the people who seek them out may be different from those who walk through (or are dragged) through the doors of a more typical clinic. But then there are the naysayers who will dismiss anything that is not evidenced based.
There is much to be learned but we need to understand them in a critical – which does not mean dismissive – way. What do we do when we want to promulgate a way of working or way of being that is harder to study within the paradigm of modern clinical research? Dismissing it entirely does not seem to be a valid option but we need to somehow remain open to critical discourse.
Perhaps some might conclude this is more of a personal than a general problem. After all, I admit to my own mistakes as I have zigged and zagged in trying to make sense of my own world and the experience of those who come to me for help. As I move now to attain a deeper understanding of humanistic and holistic approaches to helping people, I feel torn between diving in and remaining self-critical. But I suggest that we all need to monitor our own tendency for self-justification. Open, critical – respectful – discourse is of utmost importance because we need to rely on others to help us examine our own blind spots.